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i S <br /> R <br /> =..r.J.sx�.�L.ez.,i�,.R+s.:�:�<a...�ra. :xz+.-u:.. '.zt't»= <s�'sr-"c r•_ra•'.;s.-ir�tiesakTari�E_�:k :::. <� <br /> UNDERGROUND STORAGE TANK <br /> FACILITY EMPLOYEE TRAINING CERTIFICATE (Pagel of 1 ) <br /> I. FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Main Street Fuel Circle K 10181307 <br /> Business Site Address City ZIP Code <br /> 419 S . Main Manteca 95337 <br /> Il. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator Providing the Training (Print as shown on the ICC Certification.) <br /> Karen R Arnaiz <br /> Mailing Address Phone # <br /> P . O Box 162 Lodi , CA , 95241 209 518-4836 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8032295 2/3/2021 <br /> 111. FACILITY EMPLOYEE INFORMATION <br /> Individuals assuming the duties of the facility employee before October 13, 2018 must be trained within 30 days of performing <br /> facility employee duties. Individuals assuming the duties of the facility employee on and after October 13, 2018 must be trained <br /> before performing facility employee duties. <br /> Check this box If a list of the Individuals) trained Is appended to this form. The appended list, at a minimum, must contain <br /> El all of the information in this section. <br /> Date of Assuming <br /> Name of Individual(s) Trained Initial Training Date Responsibility as a <br /> Q Facility Employee <br /> l <br /> VT <br /> 2 OLI 26 <br /> i <br /> E <br /> i <br /> I <br /> IV, CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS TRAINING <br /> The facility employees listed above have completed the required training in accordance with California Code of Regulations, <br /> Title 23, Division 3, Chapter 16, Section 2715(c) and all the Information provided herein Is accurate. <br /> Training Designated US perator Si to Date of Training <br /> 1 /8/2020 <br /> CERS = Caifomia Enyronmentai Reporting System, ID = Identification, i ,Q = Intemational Code Council, UST = Uodeiground Storage Tank <br /> f <br /> 4 <br />